A nurse is receiving a change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?
A client who needs their daily weight taken with a bed scale
A client who has a leg ulcer and needs their dressing changed
A client who has an indwelling urinary catheter bag that needs to be emptied
A client who has dysphagia and has a scheduled feeding
The Correct Answer is D
A. A client who needs their daily weight taken with a bed scale: Daily weight is important for monitoring fluid status, but it is not immediately life-threatening if delayed. This task can be completed after more urgent client needs are addressed.
B. A client who has a leg ulcer and needs their dressing changed: Dressing changes are important for preventing infection and promoting healing, but this intervention is not urgent compared to risks involving airway or nutrition.
C. A client who has an indwelling urinary catheter bag that needs to be emptied: Emptying a catheter bag helps with comfort and infection control but does not represent a priority safety concern. It can safely wait until more urgent tasks are completed.
D. A client who has dysphagia and has a scheduled feeding: Dysphagia places the client at high risk for aspiration during feeding, which can compromise the airway and lead to respiratory complications. This client requires the nurse’s immediate attention to ensure safe feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,C,D,B,E
Explanation
A. Draw up a volume of air equal to the volume of insulin from the intermediate-acting insulin vial. Air is first drawn into the syringe for the intermediate-acting insulin to prevent creating a vacuum when withdrawing it later.
C. Inject the volume of air equal to the insulin dose from the short-acting insulin vial. Injecting air into the short-acting vial prevents vacuum formation and makes withdrawal easier.
D. Withdraw the prescribed amount of insulin from the short-acting insulin vial. The short-acting insulin is withdrawn first to avoid contaminating it with intermediate-acting insulin.
B. Inject the volume of air equal to the amount of insulin to withdraw from the intermediate-acting insulin vial. Air is injected into the intermediate-acting vial before withdrawal to facilitate drawing up the insulin.
E. Withdraw the prescribed amount of insulin from the intermediate-acting insulin vial. Finally, the intermediate-acting insulin is withdrawn, completing the mixture in the syringe.
Correct Answer is A
Explanation
A. Determine how the client views the concept of a family: Understanding the client’s personal definition of family helps the nurse identify who the client considers significant for support and involvement in care planning, ensuring a patient-centered approach.
B. Identify how culture influences family functioning: Cultural influences are important in understanding family dynamics, but assessing the client’s perception of family comes first. Culture shapes interactions, but only after the nurse knows who the family members are from the client’s perspective.
C. Determine if the client has an external support system: Knowing about external supports is valuable, but this information is secondary to identifying the client’s family structure and relationships. Support systems can be assessed once the family context is clear.
D. Identify how the family deals with unexpected health changes: Assessing coping strategies is necessary for planning interventions, but it should occur after the nurse has first established who comprises the client’s family and understands their roles.
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